8816 - South African Civil Aviation Authority
8816 - South African Civil Aviation Authority
8816 - South African Civil Aviation Authority
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Section/division Occurrence Investigation Form Number: CA 12-12a<br />
AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY<br />
Reference: CA18/2/3/<strong>8816</strong><br />
Aircraft Registration ZS-RME Date of accident 02 July 2010 Time of Accident 1345Z<br />
Type of Aircraft Eurocopter EC 120B Type of Operation Training<br />
Pilot-in-command Licence Type Airline transport Age 43 Licence Valid Yes<br />
Pilot-in-command Flying Experience Total Flying Hours 6 895.4 Hours on Type 75.6<br />
Last point of departure Cape Town international airport - FACT (Western Cape province).<br />
Next point of intended landing Cape Town international airport – FACT (Western Cape province).<br />
Location of the accident site with reference to easily defined geographical points (GPS readings if possible)<br />
General fling area at GPS position determined as <strong>South</strong> 33 o 58’ 12.34” East 18 o 36’ 34.30”.<br />
Meteorological Information Surface wind 190° @ 5 knots, temperature 22°C, visibility +10 km.<br />
Number of people on board 1 + 1 No. Of people injured 0 No. Of people killed 0<br />
Synopsis<br />
The helicopter with two certified pilots was involved in a training flight under Visual Flight Rules<br />
(VFR) by day. Both pilots performed a comprehensive pre-flight inspection and the aircraft was<br />
uplifted with aviation gasoline Jet A1. Take-off was normal and the aircraft headed towards Cape<br />
Town International general flying (GF) area for training purpose. It was a 6 th –monthly operator’s<br />
proficiency check (OPC) for the co-pilot (A trainee at the time of the accident). They started with<br />
the simulation of hydraulic failure followed by three simulated engine failure in hover. They<br />
climbed to 1000 feet above ground level (AGL) for autorotation practices. The first autorotation<br />
went well with the instructor closing the twist grip to ground idle and the trainee going into<br />
autorotation. The instructor again opened the twist grip to flight position during flare. The second<br />
autorotation was from a downwind position at 1000 feet AGL. The instructor closed the twist grip<br />
to ground idle and the trainee went into autorotation. The instructor looked at the Main rotor and<br />
Engine N2 (NR/NF) gauge and checked if the main rotor Revolution per Minute (RPM) was under<br />
control. The instructor then noticed that the engine RPM was winding down below normal idle<br />
indication. The instructor informed the trainee that they have lost an engine and the trainee<br />
continued with the normal procedures for autorotation till touchdown. On touchdown the aircraft<br />
still had a forward motion, skidded for approximately 3 meters. The speed reduced quite quickly<br />
as the skids dug into the soft terrain and the tail boom was chopped off by the main rotor. The<br />
aircraft was substantially damaged and no one was injured.<br />
Probable Cause<br />
Unsuccessful autorotation resulting into hard landing due to undetermined loss of engine power.<br />
IARC Date<br />
Release<br />
Date<br />
CA 12-12b 23 FEBRUARY 2006 Page 1 of 13
Section/division<br />
Occurrence Investigation Form Number: CA 12-12a<br />
Telephone number: 011-545-1408 E-mail address of originator:<br />
AIRCRAFT ACCIDENT REPORT<br />
Name of Owner/Operator : Titan Helicopters<br />
Manufacturer : Eurocopter<br />
Model : Eurocopter EC 120B<br />
Nationality : <strong>South</strong> <strong>African</strong><br />
Registration Marks : ZS-RME<br />
Place : Cape Town International<br />
Date : 02 July 2010.<br />
Time : 1345Z<br />
All times given in this report is Co-ordinated Universal Time (UTC) and will be denoted by (Z). <strong>South</strong> <strong>African</strong><br />
Standard Time is UTC plus 2 hours.<br />
Purpose of the Investigation:<br />
In terms of Regulation 12.03.1 of the <strong>Civil</strong> <strong>Aviation</strong> Regulations (1997) this report was compiled in the interest of<br />
the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and not to<br />
establish legal liability.<br />
Disclaimer:<br />
This report is given without prejudice to the rights of the CAA, which are reserved.<br />
1. FACTUAL INFORMATION:<br />
1.1 History of flight:<br />
1.1.1 The helicopter with two licensed pilots was involved in a training flight under Visual<br />
Flight Rules (VFR) by day. Both pilots performed a comprehensive pre-flight inspection<br />
and the aircraft was uplifted with aviation gasoline Jet A1. Take-off was normal and the<br />
aircraft headed towards Cape Town International general flying (GF) area for training<br />
purpose. It was a 6 th –monthly operator’s proficiency check (OPC) for the co-pilot<br />
(trainee at the time of the accident). They started with the simulation of hydraulic<br />
failure followed by three simulated engine failure in hover. They climbed to 1000 feet<br />
above ground level (AGL) for autorotation practices. The first autorotation went well<br />
with the instructor closing the twist grip to ground idle and the trainee going into<br />
autorotation. The instructor again opened the twist grip to flight position during flare.<br />
The second autorotation was from a downwind position at 1000 feet AGL.<br />
1.1.2 The instructor closed the twist grip to ground idle and the trainee went into<br />
autorotation. The instructor looked at the Main rotor and Engine N2 (NR/NF) gauge<br />
and checked if the main rotor Revolution per Minute (RPM) was under control. The<br />
instructor then noticed that the engine RPM was winding down below normal idle<br />
indication. The instructor informed the trainee that they have lost an engine and the<br />
trainee continued with the normal procedures for autorotation till touchdown. On<br />
touchdown the aircraft still had a forward motion, skidded for approximately 3 meters.<br />
The speed reduced quite quickly as the skids dug into the soft terrain and the tail boom<br />
was chopped off by the main rotor. Debris was noticed flying out to the left of the<br />
aircraft and the aircraft was substantially damaged.<br />
CA 12-12b 23 FEBRUARY 2006 Page 2 of 13
1.1.3 The airport Air Traffic Control (ATC) was notified of the situation and the airport crash<br />
alarm was immediately activated. The airport fire and rescue services dispatched to<br />
the accident site and both pilots vacated the aircraft unharmed. The accident<br />
happened during daylight conditions at GPS position determined to be S33 o 58’ 12.34”<br />
E18 o 36’ 34.30”.<br />
1.2 Injuries to persons:<br />
Injuries Pilot Crew Pass. Other<br />
Fatal - - - -<br />
Serious - - - -<br />
Minor - - - -<br />
None 2 - - -<br />
1.3 Damage to aircraft:<br />
1.3.1 The main rotor blades made contact with the tail boom and the tail boom was chopped<br />
off. The main rotor blades were damaged, the pitot tube was damaged and the right<br />
hand wind screen broke during the accident sequence. Note: In order to determine the<br />
full extent of the damage, the helicopter would have to undergo extensive inspection<br />
due to the unknown stresses placed on the airframe and the skids.<br />
Figure 1: View of the helicopter at the accident site.<br />
1.4 Other damage:<br />
1.4.1 Nil.<br />
CA 12-12b 23 FEBRUARY 2006 Page 3 of 13
1.5 Personnel information:<br />
Trainee: (Pilot flying).<br />
Nationality <strong>South</strong> <strong>African</strong> Gender Male Age 43<br />
Licence Number ########### Licence Type Airline transport<br />
Licence valid Yes Type Endorsed Yes<br />
Ratings<br />
Night Rating, Instrument Rating, Instructor Rating,<br />
Under Sling, Winching and Test pilot rating.<br />
Medical Expiry Date 31 October 2010<br />
Restrictions None<br />
Previous Accidents Nil<br />
Flying experience:<br />
Total Hours 6895.4<br />
Total Past 90 Days 5.7<br />
Total on Type Past 90 Days 51.0<br />
Total on Type 75.6<br />
Instructor: (Pilot not flying).<br />
Nationality <strong>South</strong> <strong>African</strong> Gender Male Age 57<br />
Licence Number ############ Licence Type Airline transport<br />
Licence valid Yes Type Endorsed Yes<br />
Ratings<br />
Night Rating, Instrument Rating, Instructor Rating,<br />
Under Sling, Winching and Test pilot Rating.<br />
Medical Expiry Date 30 September 2010<br />
Restrictions Corrective lenses<br />
Previous Accidents Nil<br />
Flying experience:<br />
Total Hours ±10400<br />
Total Past 90 Days 10<br />
Total on Type Past 90 Days 0.4<br />
Total on Type ±600<br />
1.6 Aircraft information:<br />
Aircraft description:<br />
An EC 120B is a medium five-seat helicopter, powered with a three-blade<br />
rotor system. It is manufactured in Turbomecca France and frequently used as a lowcost<br />
aircraft.<br />
CA 12-12b 23 FEBRUARY 2006 Page 4 of 13
Airframe:<br />
Type EC 120B<br />
Serial No. 1132<br />
Manufacturer Eurocopter<br />
Date of Manufacture 2000<br />
Total Airframe Hours (At time of accident) 2149.8<br />
Last MPI (Hours & Date) 2139.4 07 April 2010<br />
Hours since Last MPI 10.4<br />
C of A (Issue Date) 29 September 2000<br />
C of A (Expiry Date) 28 September 2010<br />
C of R (Issue Date) (Present owner) 03 October 2010<br />
Operating Categories Standard<br />
A´D and S´B Status Complied<br />
Aircraft Weight 1800 kg<br />
Recommended fuel used Jet A1<br />
Note: The last MPI (Mandatory periodic inspection) that was carried out on the<br />
helicopter prior to the accident was certified at 2131.4 hours on 07 April 2010 by the<br />
AMO (Aircraft Maintenance Organisation). The person who certified the task held a<br />
valid approved person accreditation from the CAA as well as an AME (Aircraft<br />
Maintenance Engineer) licence.<br />
Previous Accidents<br />
and Incidents<br />
Engine:<br />
On 10 October 2001 at 1150Z. The fuel vehicle was<br />
parked next to the helicopter and a gust of wind rotated<br />
the main rotor blades which subsequently made contact<br />
with the fuel vehicle׳s roll bar.<br />
On 03 December 2001 at Grand Central aerodrome<br />
(1500Z). After shut down before the pilot pulled the rotor<br />
brake, he opened the pilot door and the wind pulled the<br />
door fully opened damaging the door and the window.<br />
Type Turbomecca Arriuss 2F<br />
Serial No. 34143<br />
Hours since New 2149.4<br />
Hours since Overhaul Not reached<br />
1.7 Meteorological information:<br />
1.7.1 The following weather information was obtained from the pilot questionnaires.<br />
Wind direction 190º Wind speed 5 Knots Visibility 10km<br />
Temperature 22ºC Cloud cover Few Cloud base 10.000<br />
Dew point 10ºC<br />
CA 12-12b 23 FEBRUARY 2006 Page 5 of 13
1.8 Aids to navigation:<br />
1.8.1 The helicopter was fitted with standard navigation equipment for this helicopter type as<br />
approved at the time of certification.<br />
1.9 Communications:<br />
1.9.1 No difficulties with communications were known or reported prior to the accident. No<br />
malfunction of any of the equipment was reported at the time of the accident.<br />
1.10 Aerodrome information:<br />
Aerodrome Location Cape Town International<br />
Aerodrome Co-ordinates S33º 58׳05.2׳ E018º 36׳16.7׳.<br />
Aerodrome Elevation 151 feet AMSL<br />
Aerodrome Status Licensed<br />
Runway Designations 01/19 3 322 x 300<br />
Runway Dimensions 16/34 1 820 x 150<br />
Runway Used Runway 34<br />
Runway Surface Asphalt<br />
Approach Facilities PAPI, NDB,ILS, VOR, DME, Runway lighting<br />
1.11 Flight recorders:<br />
1.11.1 The helicopter was not fitted with a flight data recorder (FDR) or a cockpit voice<br />
recorder (CVR), neither was it required in terms of the <strong>South</strong> <strong>African</strong> <strong>Civil</strong> <strong>Aviation</strong><br />
Regulations to be fitted to this aircraft type.<br />
1.12 Wreckage and impact information:<br />
1.12.1 The aircraft landed on threshold runway 34 and after landing the tail boom was<br />
chopped off. The wind screen was damaged, pitot tube was damaged and the main<br />
rotor blades were damaged during the accident sequence. The position of the twist<br />
grip was on fully open position (flight idle) at the time of inspection and the indication<br />
on the fuel control unit (FCU) quadrant was on 60º.<br />
CA 12-12b 23 FEBRUARY 2006 Page 6 of 13
Figure 2: Position of the twist grip as found after the accident.<br />
Figure 3: Quadrant position on 60º.<br />
1.12.2 The fuel shut off valve was found in OFF/Closed position.<br />
CA 12-12b 23 FEBRUARY 2006 Page 7 of 13
Figure 4: View of the fuel shut off valve on the aircraft cockpit roof.<br />
1.13 Medical and pathological information:<br />
1.13.1 Both pilots sustained no injuries as result of this accident.<br />
1.14 Fire:<br />
1.14.1 There was no evidence of pre- and post-impact fire<br />
1.15 Survival aspects:<br />
1.15.1 The accident was considered survivable because both occupants were properly<br />
restrained and secured by making use of safety harnesses.<br />
1.15.2 The cockpit/cabin area remained intact after the accident sequence.<br />
1.16 Tests and research:<br />
1.16.1 After the accident the aircraft was recovered by a crane to the hanger where further<br />
investigation were carried out by two certified Engineers under the auspices of the SA<br />
CAA accident investigators.<br />
INSPECTIONS PERFORMED:<br />
They checked if they could turn the twist grip to off position without<br />
powering the aircraft and it was not possible.<br />
CA 12-12b 23 FEBRUARY 2006 Page 8 of 13
The aircraft was energized and again they tried to turn the twist grip<br />
without activating the solenoid and it was not possible.<br />
Power turbine rotation was free without evidence of metal spatter, blade<br />
tip rubbing or visual evidence of over temperature and showed a positive<br />
connection to the main gear box drive.<br />
Functioning of the cyclic and collective controls confirmed that the<br />
control systems from the pilot inputs to the hydraulic servos were<br />
correctly connected and capable of functioning appropriately.<br />
With the battery selected 'ON' it was noted that appropriate pitch change<br />
movement of the blade roots took place when the cyclic and collective<br />
controls were operated.<br />
They activated the solenoid and turned the twist grip to off position and<br />
the indication on the quadrant was +1 degrees. See figure 5 below.<br />
Figure 5: View of the fuel control unit (FCU) quadrant.<br />
The operation of the anticipator was checked and found operating<br />
normally.<br />
When moving the collective up and down and checking the indication on<br />
the quadrant of the anticipator, the reaction was normal.<br />
The twist grip was moved to idle position and the indication on the<br />
quadrant was 28º. See figure 6 and 7 below.<br />
CA 12-12b 23 FEBRUARY 2006 Page 9 of 13
Figure 6: Twist grip at idle position.<br />
Figure 7: View of the fuel control unit (FCU) quadrant at 28º.<br />
Fuel sample from the fuel tank and from the fuel filter bowl were taken<br />
and analysed > no anomaly found.<br />
Both fuel filters on the engine were removed and inspected > no<br />
anomaly found.<br />
CA 12-12b 23 FEBRUARY 2006 Page 10 of 13
The airframe fuel strainer was free from any contamination.<br />
FCU control lever input connection satisfactory.<br />
Aircraft booster pump activated and no fuel leaks noticed.<br />
Anticipator input connection satisfactory.<br />
The rigging of the fuel control was found to be in compliant with the<br />
settings specified.<br />
Oil tank sump electrical magnetic plug was contamination free.<br />
Engine oil filter was removed and inspected > no anomaly was found.<br />
Oil above minimum level.<br />
No evidence of any in-flight fuel or oil leaks.<br />
The free rotation of the compressor was checked > smooth rotation<br />
with no rubbing.<br />
Boroscopic inspection did not show any evidence of abnormal carbon<br />
accumulation or any sign to suspect adverse combustion.<br />
1.17 Organisational and management Information:<br />
1.17.1 This was a training flight.<br />
1.17.2 The last MPI (Mandatory periodic inspection) that was carried out on the helicopter<br />
prior to the accident was certified at 2131.4 hours on 07 April 2010 by the AMO<br />
(Aircraft Maintenance Organisation). The person who certified the task held a valid<br />
approved person accreditation from the CAA as well as an AME (Aircraft Maintenance<br />
Engineer) licence.<br />
1.18 Additional information:<br />
1.18.1 None.<br />
1.19 Useful or effective investigation techniques:<br />
1.19.1 None.<br />
2 ANALYSIS:<br />
2.1 Available information indicated that fine weather conditions prevailed in the area at the<br />
time of the flight and subsequent accident. The prevailing weather conditions were<br />
therefore not considered to have had any bearing on the accident.<br />
CA 12-12b 23 FEBRUARY 2006 Page 11 of 13
2.2 The helicopter was properly maintained and no documented evidence was found<br />
indicating any defect or malfunction of the helicopter prior the flight that could have<br />
contributed to or caused the accident. The helicopter had flown a total of 10.4 hours<br />
since the last maintenance inspection was certified.<br />
2.3 Both pilots held a valid pilot's licences as well as valid aviation medical certificates that<br />
were issued by a SA CAA accredited medical examiner. After the accident the<br />
helicopter was recovered to a facility where various tests and analysis were carried out<br />
and the investigation did not reveal any deficiencies. Both pilots held valid pilot's<br />
licences as well as valid aviation medical certificates that were issued by an SACAA-<br />
accredited medical examiner. After the accident, the helicopter was recovered to a<br />
facility where various tests and analyses were carried out, and the investigation did not<br />
reveal any deficiencies.<br />
2.4 The IIC proposed to the regulator that the engine be shipped to France for further<br />
analysis (test cell run), but this was not approved. In conclusion, the investigation could<br />
not establish any conclusive reason why the engine stopped/flamed out; however,<br />
unintentional shut-down of the engine could not be eliminated as a possible or<br />
contributing factor to this accident.<br />
3. CONCLUSION:<br />
3.1 Findings:<br />
i. Both pilots had Airline transport licences with the aircraft type endorsed in their<br />
logbooks.<br />
ii. The pilots were involved in a training flight under Visual flight Rules (VFR) by<br />
day.<br />
iii. Both pilots had ratings at the time of the accident.<br />
iv. The weather conditions were favorable for VFR flight.<br />
v. The Instructor׳s medical was valid with restrictions to put on Corrective lenses<br />
at the time of the accident.<br />
vi. The aircraft was involved in two (2) incidents.<br />
vii. All control surfaces were accounted for and there was no evidence of any<br />
defect or malfunction on the aircraft that could have contributed or have caused<br />
the accident.<br />
viii. The accident was considered survivable.<br />
CA 12-12b 23 FEBRUARY 2006 Page 12 of 13
3.2 Probable cause/s:<br />
3.2.1 Unsuccessful autorotation resulting into hard landing due to undetermined loss of<br />
engine power.<br />
3.3 Appendices:<br />
3.3.1 Nil.<br />
4. SAFETY RECOMMENDATIONS:<br />
4.1 None.<br />
Compiled by:<br />
Frans Motaung<br />
for the Commissioner for <strong>Civil</strong> <strong>Aviation</strong><br />
Date: ………………….………..<br />
Investigator-in-charge: ………………………… Date: …………………………..<br />
Co-investigator: ………………………………… Date: ……………….…………<br />
CA 12-12b 23 FEBRUARY 2006 Page 13 of 13